COPD Treatment Selection

An overview of the medication classes available for the treatment of chronic obstructive pulmonary disease and recommendations for how to utilize and in whom.


Neil B. Minkoff, MD: Let’s use that as a segue to jump into some of these medication classes. So thank you for that nice segue. We have a class of the short-acting bronchodilators. An example of that would be albuterol. But then we have 3 types of maintenance classes: the LABAs [long-acting beta-agonists], and an example would be salmeterol; the LAMAs [long-acting muscarinic antagonists], where an example would be tiotropium; and the inhaled corticosteroids [ICS therapy], where you might see fluticasone. What I’m curious about isn’t so much how you look at those drugs individually but, based on what you just said, the use of those in combination. Where do you see the use of those, and where do you think dual combination makes the most sense?

Frank C. Sciurba, MD, FCCP: The first, most important point that I would like to get across to primary care providers—and databases tell us that we have a lot of progress we need to make—is that COPD [chronic obstructive pulmonary disease], with rare exception, should be treated with long-acting maintenance drugs, OK? Now, which of the 2 or 3? We’re going to have further discussions. But what that means is it’s not an as-needed albuterol or as-needed Combivent [ipratropium/salbutamol]. These drugs are gone in 3 to 6 hours, and patients rarely take enough to cover them throughout the day. That impacts not only their symptoms but exacerbation frequency. We have proven that long-acting inhalers, meaning twice-a-day or once-a-day inhalers—and the 3 classes are long-acting muscarinic antagonists, long-acting beta agonists, and inhaled corticosteroids in various combinations—all have proven to decrease flare-ups, which impact their lives and impact the cost of healthcare. So No. 1, long-acting bronchodilators. Everything else is an important nuance, but that’s climbing the mountain.

Neil B. Minkoff, MD: OK.

Byron Thomashow, MD: I agree with what Frank says. There are, as Frank says, guidelines that are available to us, and there are nuances that differ between guidelines. Their overall approach is the same, with the concept that short-acting beta-agonists, which are a mainstay in the treatment of asthma, for example, are not the mainstay in the treatment of COPD. COPD should be treated with maintenance therapies. Most of us start, in more mild disease, with the long-acting muscarinics that Frank was talking about. And GOLD tends to suggest that you start with 1 and add as you go.

Neil B. Minkoff, MD: That was my next question. Is that really what you’re doing?

Byron Thomashow, MD: I think Frank and I do the same thing. If I’ve got a patient with significant disease and significant symptoms, I’m actually starting them on a LAMA and a LABA at the same time. I think the evidence demonstrates that those drugs are more effective than either of the agents alone. And thankfully there’s no evidence that there is increased risk of those agents alone. And the data on the third group of drugs that we have, the ICS, suggests that predominantly, if not completely, they are for those patients who have more frequent exacerbations.

All this may change as we go along. Part of the problem is we all understand that in many people, particularly with the airway disease, with the bronchitic component, there’s a major inflammatory component. And steroids may not ultimately be the best choice for that—inhaled corticosteroids. These are things that we talk about, but I think the mainstay of therapy are LAMAs and LABAs, and then we add on from there. I assume you agree with that?

Frank C. Sciurba, MD, FCCP: I do.

Neil B. Minkoff, MD: Let me ask you a question as just a lowly internist here. Who gets the LABAs and LAMAs, and who gets the LABAs with corticosteroids? Which types of patients end up on which therapies?

Frank C. Sciurba, MD, FCCP: In asthma, I always says you lead with the inhaled corticosteroid to shut down the symptoms. And often, those patients no longer have obstruction. They don’t even need bronchodilators, except for, as Byron said, as-needed short-acting for symptoms. In COPD, they are incompletely reversible by definition. Even when you maximally treat them, you can’t completely reverse them. And that often is associated, regardless of how well you treat them, that you can improve symptoms but you can’t eliminate symptoms.

So we lead with the long-acting bronchodilators. And Byron and I both feel similarly that in patients who often present—certainly to pulmonologists but often even to primary care doctors—they’re in the more moderate to severe stage. You could slowly work your way up to maximal treatment, but in almost all cases, they’re all going to be on both the LABA and the LAMA. And so very often we’ll start the LABA and LAMA, which means that a LABA/ICS is almost never the right thing to start with.

In somebody who has symptoms and is frequently exacerbating, or some of us are looking at eosinophil counts as a guidance. We’ll go with a LABA/LAMA and the inhaled corticosteroid right out of the gates. But in almost all cases, we work our way up to LABA/LAMA. That is fundamental to patients with moderate to severe disease with persistent symptoms across the board. The ICS—I’ll let Byron begin to describe the nuance, and when we want an ICS and when we don’t. But I think the bronchodilators maximally bronchodilated is fundamental to all patients who have persistent symptoms.

Byron Thomashow, MD: Yeah, I would agree with that completely. The interesting thing is that not only is the LAMA/LABA oftentimes very effective in their symptoms, but there’s evidence suggesting they’re reasonably good for exacerbations as well. Now, if you have someone with ongoing exacerbations, then you would think about adding the ICS component. If you have somebody with really quite severe disease, I would suggest that many of us have pathways in our hospitals on how to deal with that. I think that if you have someone who’s been bad enough with bad enough disease to be hospitalized, you could make a pretty strong argument based on some of the data existing now that they should be discharged on a triple regimen. I think that is a possibility.

The only other thing I want to bring up—and I’m not trying to confuse anybody, but it does come up in primary care a lot—is the confusing issue of an overlap between asthma and COPD. What is the difference between it? And I’m sure, Maria, you deal with this a lot from your standpoint. It’s complicated because for a primary care doctor, even for a pulmonologist who’s been in practice for many years, as Frank and I have, it’s sometimes not completely clear. That’s a subset that primary care might look at and say, “I don’t know for sure what it is. I know it’s important to have an inhaled corticosteroid in the asthmatic population, so it’s just easier for me to use that.” That comes, again, to education and defining the nature of the diseases you’re dealing with.

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